Your browser doesn't support javascript.
loading
Mostrar: 20 | 50 | 100
Resultados 1 - 20 de 115
Filtrar
1.
Surg Endosc ; 37(7): 5665-5672, 2023 07.
Artigo em Inglês | MEDLINE | ID: mdl-36658282

RESUMO

INTRODUCTION: Artificial intelligence (AI) can automate certain tasks to improve data collection. Models have been created to annotate the steps of Roux-en-Y Gastric Bypass (RYGB). However, model performance has not been compared with individual surgeon annotator performance. We developed a model that automatically labels RYGB steps and compares its performance to surgeons. METHODS AND PROCEDURES: 545 videos (17 surgeons) of laparoscopic RYGB procedures were collected. An annotation guide (12 steps, 52 tasks) was developed. Steps were annotated by 11 surgeons. Each video was annotated by two surgeons and a third reconciled the differences. A convolutional AI model was trained to identify steps and compared with manual annotation. For modeling, we used 390 videos for training, 95 for validation, and 60 for testing. The performance comparison between AI model versus manual annotation was performed using ANOVA (Analysis of Variance) in a subset of 60 testing videos. We assessed the performance of the model at each step and poor performance was defined (F1-score < 80%). RESULTS: The convolutional model identified 12 steps in the RYGB architecture. Model performance varied at each step [F1 > 90% for 7, and > 80% for 2]. The reconciled manual annotation data (F1 > 80% for > 5 steps) performed better than trainee's (F1 > 80% for 2-5 steps for 4 annotators, and < 2 steps for 4 annotators). In testing subset, certain steps had low performance, indicating potential ambiguities in surgical landmarks. Additionally, some videos were easier to annotate than others, suggesting variability. After controlling for variability, the AI algorithm was comparable to the manual (p < 0.0001). CONCLUSION: AI can be used to identify surgical landmarks in RYGB comparable to the manual process. AI was more accurate to recognize some landmarks more accurately than surgeons. This technology has the potential to improve surgical training by assessing the learning curves of surgeons at scale.


Assuntos
Derivação Gástrica , Laparoscopia , Obesidade Mórbida , Cirurgiões , Humanos , Derivação Gástrica/métodos , Obesidade Mórbida/cirurgia , Inteligência Artificial , Gastrectomia/métodos , Laparoscopia/métodos , Estudos Retrospectivos
2.
Community Ment Health J ; 59(2): 370-380, 2023 02.
Artigo em Inglês | MEDLINE | ID: mdl-36001197

RESUMO

Rising psychiatric emergency department (ED) presentations pose significant financial and administrative burdens to hospitals. Alternative psychiatric emergency services programs have the potential to alleviate this strain by diverting non-emergent mental health issues from EDs. This study explores one such program, the Boston Emergency Services Team (BEST), a multi-channel psychiatric emergency services provider intended for the publicly insured and uninsured population. BEST provides evaluation and treatment for psychiatric crises through specialized psychiatric EDs, a 24/7 hotline, psychiatric urgent care centers, and mobile crisis units. This retrospective review examines the sociodemographic and clinical characteristics of 225,198 BEST encounters (2005-2016). Of note, the proportion of encounters taking place in ED settings decreased significantly from 70 to 58% across the study period. Findings suggest that multi-focal, psychiatric emergency programs like BEST have the potential to reduce the burden of emergency mental health presentations and improve patient diversion to appropriate psychiatric care.


Assuntos
Serviços de Emergência Psiquiátrica , Serviços de Saúde Mental , Humanos , Boston , Saúde Mental , Serviço Hospitalar de Emergência
3.
Clin Infect Dis ; 73(9): e2484-e2492, 2021 11 02.
Artigo em Inglês | MEDLINE | ID: mdl-32756935

RESUMO

BACKGROUND: Among those with injection drug use-associated infective endocarditis (IDU-IE), against medical advice (AMA) discharge is common and linked to adverse outcomes. Understanding trends, risk factors, and timing is needed to reduce IDU-IE AMA discharges. METHODS: We identified individuals ages 18-64 with International Classification of Diseases, 9thRevision, diagnosis codes for infective endocarditis (IE) in the National Inpatient Sample, a representative sample of United States hospitalizations from January 2010 to September 2015. We plotted unadjusted quarter-year trends for AMA discharges and used multivariable logistic regression to identify factors associated with AMA discharge among IE hospitalizations, comparing IDU-IE with non-IDU-IE. RESULTS: We identified 7259 IDU-IE and 23 633 non-IDU-IE hospitalizations. Of these hospitalizations, 14.2% of IDU-IE and 1.9% of non-IDU-IE resulted in AMA discharges. More than 30% of AMA discharges for both groups occurred before hospital day 3. In adjusted models, IDU status (adjusted odds ratio [AOR], 3.92; 95% confidence interval [CI], 3.43-4.48)] was associated with increased odds of AMA discharge. Among IDU-IE, women (AOR, 1.21; 95% CI, 1.04-1.41) and Hispanics (AOR, 1.32; 95% CI, 1.03-1.69) had increased odds of AMA discharge, which differed from non-IDU-IE. Over nearly 6 years, odds of AMA discharge increased 12% per year for IDU-IE (AOR, 1.12; 95% CI, 1.07-1.18) and 6% per year for non-IDU-IE (AOR, 1.06; 95% CI. 1.00-1.13). CONCLUSIONS: AMA discharges have risen among individuals with IDU-IE and non-IDE-IE. Among those who inject drugs, AMA discharges were more common and increases sharper. Efforts that address the rising fraction, disparities, and timing of IDU-IE AMA discharges are needed.


Assuntos
Endocardite , Preparações Farmacêuticas , Adolescente , Adulto , Estudos de Coortes , Endocardite/epidemiologia , Feminino , Humanos , Pessoa de Meia-Idade , Alta do Paciente , Estudos Retrospectivos , Estados Unidos/epidemiologia , Adulto Jovem
4.
J Vasc Surg ; 74(2): 499-504, 2021 08.
Artigo em Inglês | MEDLINE | ID: mdl-33548437

RESUMO

OBJECTIVE: Despite published guidelines and data for Medicare patients, it is uncertain how younger patients with intermittent claudication (IC) are treated. Additionally, the degree to which treatment patterns have changed over time with the expansion of endovascular interventions and outpatient centers is unclear. Our goal was to characterize IC treatment patterns in the commercially insured non-Medicare population. METHODS: The IBM MarketScan Commercial Database, which includes more than 8 billion US commercial insurance claims, was queried for patients newly diagnosed with IC from 2007 to 2016. Patient demographics, medication profiles, and open/endovascular interventions were evaluated. Time trends were modeled using simple linear regression and goodness-of-fit was assessed with coefficients of determination (R2). A patient-centered cohort sample and a procedure-focused dataset were analyzed. RESULTS: Among 152,935,013 unique patients in the database, there were 300,590 patients newly diagnosed with IC. The mean insurance coverage was 4.4 years. The median patients age was 58 years and 56% of patients were male. The prevalence of statin use was 48% among patients at the time of IC diagnosis and increased to 52% among patients after one year from diagnosis. Interventions were performed in 14.3%, of whom 20% and 6% underwent two or more and three or more interventions, respectively. The median time from diagnosis to intervention decreased from 230 days in 2008 days to 49 days in 2016 (R2 = 0.98). There were 16,406 inpatient and 102,925 ambulatory interventions for IC over the study period. Among ambulatory interventions, 7.9% were performed in office-based/surgical centers. The proportion of atherectomies performed in the ambulatory setting increased from 9.7% in 2007 to 29% in 2016 (R2 = 0.94). In office-based/surgical centers, 57.6% of interventions for IC used atherectomy in 2016. Atherectomy was used in ambulatory interventions by cardiologists in 22.6%, surgeons in 15.2%, and radiologists in 13.6% of interventions. Inpatient atherectomy rates remained stable over the study period. Open and endovascular tibial interventions were performed in 7.9% and 7.8% of ambulatory and inpatient IC interventions, respectively. Tibial bypasses were performed in 8.2% of all open IC interventions. CONCLUSIONS: There has been shorter time to intervention in the treatment of younger, commercially insured patients with IC, with many receiving multiple interventions. Statin use was low. Ambulatory procedures, especially in office-based/surgical centers, increasingly used atherectomy, which was not observed in inpatient settings.


Assuntos
Aterectomia/tendências , Procedimentos Endovasculares/tendências , Claudicação Intermitente/terapia , Medicare/tendências , Padrões de Prática Médica/tendências , Procedimentos Cirúrgicos Vasculares/tendências , Fatores Etários , Assistência Ambulatorial/tendências , Cardiologistas/tendências , Bases de Dados Factuais , Feminino , Hospitalização/tendências , Humanos , Inibidores de Hidroximetilglutaril-CoA Redutases/uso terapêutico , Claudicação Intermitente/diagnóstico , Masculino , Pessoa de Meia-Idade , Indicadores de Qualidade em Assistência à Saúde/tendências , Radiologistas/tendências , Estudos Retrospectivos , Cirurgiões/tendências , Fatores de Tempo , Tempo para o Tratamento/tendências , Resultado do Tratamento , Estados Unidos
5.
Ann Vasc Surg ; 71: 65-73, 2021 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-32949743

RESUMO

BACKGROUND: Length of stay (LOS) after carotid endarterectomy (CEA) and carotid artery stenting (CAS) for asymptomatic disease is used as a quality measure and affects hospital operating margins. Patient-level Medicaid status has traditionally been associated with longer hospital LOS. Our goal was to assess the association between hospital-level Medicaid prevalence and postoperative LOS after CEA and CAS. METHODS: The National Inpatient Sample was queried from 2006-2014 for CEA and CAS performed for asymptomatic carotid stenosis. Overall hospital-level Medicaid prevalence was divided into quartiles. The quartiles were further categorized into low Medicaid prevalence (LM) (lowest quartile), medium Medicaid prevalence (MM) (second and third quartiles), and high Medicaid prevalence (HM) (fourth quartile) cohorts. The primary outcome evaluated was postoperative LOS >1 day. The secondary outcomes included perioperative/in-hospital complications and mortality. RESULTS: There were 984,283 patients with asymptomatic carotid stenosis who underwent CEA (88%) or CAS (12%). Mean postoperative LOS after CEA at hospitals with LM, MM, and HM prevalence was 1.4 ± 1.5, 2.1 ± 2.5, and 2.2 ± 2.8 days (P = 0.0001), respectively, and after CAS were 1.7 ± 2.6, 1.8 ± 2.1, and 2 ± 2.6 days (P < 0.0001), respectively. After CEA, relative to LM prevalence, MM (OR 1.62, 95% CI 1.17-2.24) and HM (OR 1.66, 95% CI 1.2-2.28) prevalence were associated with a higher likelihood of LOS > 1 day (P = 0.009). After CAS, relative to LM prevalence, HM prevalence was associated with a higher likelihood of LOS >1 day (OR 1.42, 95% CI 1.06-1.91) (P = 0.003). After CEA, neurologic (0.8% vs. 0.9% vs. 0.9%, P = 0.83) and cardiac complications (0.9% vs. 1.2% vs. 1.2%, P = 0.24) were similar among hospitals with LM, MM, and HM prevalence, respectively. After CAS, the prevalence of neurological (1.1% vs. 1% vs. 1.2%, P = 0.42) and cardiac complications (2% vs. 1.3% vs. 1.5%, P = 0.46) were also similar. After both CEA and CAS, mortality was similar among Medicaid prevalence cohorts. CONCLUSIONS: Higher hospital-level Medicaid prevalence was associated with longer LOS after CEA and CAS for asymptomatic carotid stenosis. Value-based payment models should adjust for hospital-level Medicaid prevalence to appropriately reimburse providers and hospital with higher Medicaid prevalence as well as investigate care pathways and systems improvement to help reduce LOS.


Assuntos
Estenose das Carótidas/terapia , Endarterectomia das Carótidas , Procedimentos Endovasculares/instrumentação , Tempo de Internação , Medicaid , Stents , Idoso , Idoso de 80 Anos ou mais , Estenose das Carótidas/diagnóstico por imagem , Estenose das Carótidas/mortalidade , Bases de Dados Factuais , Endarterectomia das Carótidas/efeitos adversos , Endarterectomia das Carótidas/mortalidade , Procedimentos Endovasculares/efeitos adversos , Procedimentos Endovasculares/mortalidade , Feminino , Mortalidade Hospitalar , Humanos , Pacientes Internados , Masculino , Medicare , Pessoa de Meia-Idade , Complicações Pós-Operatórias/mortalidade , Estudos Retrospectivos , Fatores de Tempo , Resultado do Tratamento , Estados Unidos/epidemiologia
6.
Clin Infect Dis ; 71(3): 480-487, 2020 07 27.
Artigo em Inglês | MEDLINE | ID: mdl-31598642

RESUMO

BACKGROUND: Injection drug use-associated infective endocarditis (IDU-IE) is rising and valve surgery is frequently indicated. The effect of initiating public outcomes reporting for aortic valve surgery on rates of valve surgery and in-hospital mortality for endocarditis is not known. METHODS: For an interrupted time series analysis, we used data from the National Inpatient Sample, a representative sample of United States inpatient hospitalizations, from January 2010 to September 2015. We included individuals aged 18-65 with an International Classification of Diseases, Ninth Revision (ICD-9) diagnosis of endocarditis. We defined IDU-IE using a validated combination of ICD-9 codes. We used segmented logistic regression to assess for changes in valve replacement and in-hospital mortality rates after the public reporting initiation in January 2013. RESULTS: We identified 7322 hospitalizations for IDU-IE and 23 997 for non-IDU-IE in the sample, representing 36 452 national IDU-IE admissions and 119 316 non-IDU admissions, respectively. Following the implementation of public reporting in 2013, relative to baseline trends, the odds of valve replacement decreased by 4.0% per quarter (odds ratio [OR] 0.96, 95% confidence interval [CI] 0.93-0.99), with no difference by IDU status. The odds of an in-patient death decreased by 2.0% per quarter for both IDU-IE and non-IDU-IE cases following reporting (OR 0.98, 95% CI 0.97-0.99). CONCLUSIONS: Initiating public reporting was associated with a significant decrease in valve surgery for all IE cases, regardless of IDU status, and a reduction in-hospital mortality for patients with IE. Patients with IE may have less access to surgery as a consequence of public reporting. To understand how reduced valve surgery impacts overall mortality, future studies should examine the postdischarge mortality rate.


Assuntos
Endocardite , Preparações Farmacêuticas , Adolescente , Adulto , Assistência ao Convalescente , Idoso , Valva Aórtica/cirurgia , Endocardite/epidemiologia , Endocardite/cirurgia , Mortalidade Hospitalar , Humanos , Pessoa de Meia-Idade , Alta do Paciente , Estudos Retrospectivos , Estados Unidos/epidemiologia , Adulto Jovem
7.
J Vasc Surg ; 72(4): 1298-1304.e1, 2020 10.
Artigo em Inglês | MEDLINE | ID: mdl-32115320

RESUMO

OBJECTIVE: Firearm injuries have traditionally been associated with worse outcomes compared with other types of penetrating trauma. Lower extremity trauma with vascular injury is a common presentation at many centers. Our goal was to compare firearm and non-firearm lower extremity penetrating injuries requiring vascular repair. METHODS: We analyzed the National Inpatient Sample from 2010 to 2014 for all penetrating lower extremity injuries requiring vascular repair based on International Classification of Diseases, Ninth Revision codes. Our primary outcomes were in-hospital lower extremity amputation and death. RESULTS: We identified 19,494 patients with lower extremity penetrating injuries requiring vascular repair-15,727 (80.7%) firearm injuries and 3767 (19.3%) non-firearm injuries. The majority of patients were male (91%), and intent was most often assault/legal intervention (64.3%). In all penetrating injuries requiring vascular repair, the majority (72.9%) had an arterial injury and 43.8% had a venous injury. Location of vascular injury included iliac (19.3%), femoral-popliteal (60%), and tibial (13.2%) vascular segments. Interventions included direct vascular repair (52.1%), ligation (22.1%), bypass (19.4%), and endovascular procedures (3.6%). Patients with firearm injuries were more frequently younger, black, male, and on Medicaid, with lower household income, intent of assault or legal action, and two most severe injuries in the same body region (P < .0001 for all). Firearm injuries compared with non-firearm injuries were more often reported to be arterial (75.5% vs 61.9%), to involve iliac (20.6% vs 13.7%) and femoral-popliteal vessels (64.7% vs 39.9%), to undergo endovascular repair (4% vs 2.1%), and to have a bypass (22.5% vs 6.5%; P < .05 for all). Firearm-related in-hospital major amputation (3.3% vs 0.8%; P = .001) and mortality (7.6% vs 4.2%; P = .001) were higher compared with non-firearm penetrating trauma. Multivariable analysis showed that injury by a firearm source was independently associated with postoperative major amputation (odds ratio, 4.78; 95% confidence interval, 2.07-11.01; P < .0001) and mortality (odds ratio, 1.74; 95% confidence interval, 1.14-2.65; P = .01). CONCLUSIONS: Firearm injury is associated with a higher rate of amputation and mortality compared with non-firearm injuries of the lower extremity requiring vascular repair. These data can continue to guide public health discussions about morbidity and mortality from firearm injury.


Assuntos
Amputação Cirúrgica/estatística & dados numéricos , Extremidade Inferior/lesões , Lesões do Sistema Vascular/cirurgia , Ferimentos por Arma de Fogo/cirurgia , Ferimentos Penetrantes/cirurgia , Adolescente , Adulto , Artérias/lesões , Criança , Pré-Escolar , Bases de Dados Factuais/estatística & dados numéricos , Feminino , Mortalidade Hospitalar , Humanos , Lactente , Recém-Nascido , Escala de Gravidade do Ferimento , Extremidade Inferior/irrigação sanguínea , Extremidade Inferior/cirurgia , Masculino , Medicaid/estatística & dados numéricos , Pessoa de Meia-Idade , Estudos Retrospectivos , Fatores de Risco , Fatores Sexuais , Fatores Socioeconômicos , Resultado do Tratamento , Estados Unidos/epidemiologia , Lesões do Sistema Vascular/diagnóstico , Lesões do Sistema Vascular/etiologia , Lesões do Sistema Vascular/mortalidade , Veias/lesões , Ferimentos por Arma de Fogo/complicações , Ferimentos por Arma de Fogo/diagnóstico , Ferimentos por Arma de Fogo/mortalidade , Ferimentos Penetrantes/complicações , Ferimentos Penetrantes/diagnóstico , Ferimentos Penetrantes/mortalidade , Adulto Jovem
8.
J Surg Res ; 256: 96-102, 2020 12.
Artigo em Inglês | MEDLINE | ID: mdl-32688080

RESUMO

BACKGROUND: Rural counties in the United States have higher firearm suicide rates and opioid overdoses than urban counties. We sought to determine whether rural counties can be grouped based on these "diseases of despair." METHODS: Age-adjusted firearm suicide death rates per 100,000; drug-related death rates per 100,000; homicide rate per 100,000, opioid prescribing rate, %black, %Native American, and %veteran population, median home price, violent crime rates per 100,000, primary economic dependency (nonspecialized, farming, mining, manufacturing, government, and recreation), and economic variables (low education, low employment, retirement destination, persistent poverty, and persistent child poverty) were obtained for all rural counties and evaluated with hierarchical clustering using complete linkage. RESULTS: We identified five distinct rural county clusters. The firearm suicide rates in the clusters were 5.9, 6.8, 6.4, 8.5, and 3.8 per 100,000, respectively. The counties in cluster 1 were poor, mining dependent, with population loss, cluster 2 were nonspecialized economies, with high opioid prescription rates, cluster 3 were manufacturing and government economies with moderate unemployment, cluster 4 were recreational economies with substantial veterans and Native American populations, high median home price, drug death rates, opioid prescribing, and violent crime, and cluster 5 were farming economies, with high population loss, low median home price, low rates of drug mortality, opioid prescribing, and violent crime. Cluster 4 counties were spatially adjacent to urban counties. CONCLUSIONS: More than 300 counties currently face a disproportionate burden of diseases of despair. Interventions to reduce firearm suicides should be community-based and include programs to reduce other diseases of despair.


Assuntos
Analgésicos Opioides/intoxicação , Efeitos Psicossociais da Doença , Overdose de Drogas/mortalidade , População Rural/estatística & dados numéricos , Suicídio/estatística & dados numéricos , Ferimentos por Arma de Fogo/mortalidade , Adolescente , Adulto , Causas de Morte , Centers for Disease Control and Prevention, U.S./estatística & dados numéricos , Criança , Análise por Conglomerados , Estudos Transversais , Bases de Dados Factuais/estatística & dados numéricos , Overdose de Drogas/etiologia , Overdose de Drogas/prevenção & controle , Feminino , Geografia , Disparidades nos Níveis de Saúde , Humanos , Masculino , Pessoa de Meia-Idade , Fatores de Risco , Fatores Socioeconômicos , Estados Unidos/epidemiologia , Ferimentos por Arma de Fogo/prevenção & controle , Adulto Jovem , Prevenção do Suicídio
9.
J Vasc Surg ; 69(5): 1524-1531.e1, 2019 05.
Artigo em Inglês | MEDLINE | ID: mdl-31010517

RESUMO

OBJECTIVE: Firearm injuries have high morbidity and mortality. Presentation of injuries requiring concurrent vascular repair and its outcomes are unclear. Our study's objective was to characterize the injury details and to assess the associated mortality and morbidity after vascular repair. METHODS: The National Inpatient Sample was queried from 1993 to 2014 for all firearm injuries. International Classification of Diseases, Ninth Revision codes were used to identify firearm injuries and those who also underwent a vascular repair. Multivariable analysis was used to assess the effect of a concurrent vascular repair on outcomes. RESULTS: There were 648,662 firearm injuries identified; 63,973 (9.9%) involved a vascular repair. Overall, 88.7% of patients were male, and Medicaid was the most common insurance (40.2%). Intents were assault or legal intervention (60%), unintentional (24.2%), and suicide (8.6%). Patients undergoing vascular repair were younger, more often of black race and male sex, and on Medicaid insurance, with a lower household income and assault/legal intent (P < .005). Patients who underwent vascular repair had a higher frequency of abdomen/pelvis and extremity injuries as well as an elevated New Injury Severity Score (P < .005). Patients with vascular repair were more frequently treated at urban, teaching, and large hospitals (P < .005). Overall mortality rate was 2.2%; patients who underwent vascular repair had a higher mortality compared with those without (5.51% vs 1.98%; P < .001). Patients with vascular repair had higher rates of acute renal failure (3.1% vs 0.8%), venous thromboembolic events (0.5% vs 0.3%), pulmonary-related events (0.6% vs 0.28%), cardiac-related events (0.8% vs 0.2%), sepsis (1.4% vs 0.5%), and any complication (5.7% vs 2%; all P < .0001). Vascular repair was independently associated with mortality (odds ratio [OR], 2.68; 95% confidence interval [CI], 2.43-2.95; P < .0001). Age older than 46 years (OR, 2.01; 95% CI, 1.71-2.35; P < .0001), male sex (OR, 1.15; 95% CI, 1.05-1.25; P = .003), self-pay/no insurance (OR, 1.6; 95% CI, 1.47-1.75; P < .0001), suicide intent (OR, 3.73; 95% CI, 3.36-4.13; P < .0001), unintentional intent (OR, 1.12; 95% CI, 1.03-1.22; P < .0001), head/neck location (OR, 13.9; 95% CI, 12.5-15.6; P < .0001), Northeast region, and New Injury Severity Score >4 were independently associated with in-hospital mortality. Vascular repair was also independently associated with any complication (OR, 2.12; 95% CI, 1.98-2.28; P < .0001). CONCLUSIONS: Firearm injuries with vascular repair were independently associated with higher injury severity score and mortality. A majority of vascular repairs were performed for injury to the abdomen/pelvis and extremity with assault/legal intent, whereas head and neck injury and suicide intent were the least frequent.


Assuntos
Armas de Fogo , Complicações Pós-Operatórias/epidemiologia , Procedimentos Cirúrgicos Vasculares/efeitos adversos , Lesões do Sistema Vascular/cirurgia , Ferimentos por Arma de Fogo/cirurgia , Adolescente , Adulto , Criança , Pré-Escolar , Bases de Dados Factuais , Feminino , Mortalidade Hospitalar , Humanos , Incidência , Lactente , Recém-Nascido , Escala de Gravidade do Ferimento , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/mortalidade , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , Estados Unidos/epidemiologia , Procedimentos Cirúrgicos Vasculares/mortalidade , Lesões do Sistema Vascular/diagnóstico , Lesões do Sistema Vascular/mortalidade , Ferimentos por Arma de Fogo/diagnóstico , Ferimentos por Arma de Fogo/mortalidade , Adulto Jovem
10.
Am J Public Health ; 109(12): 1702-1706, 2019 12.
Artigo em Inglês | MEDLINE | ID: mdl-31622141

RESUMO

Current injury surveillance systems in the United States, including the National Electronic Injury Surveillance System (NEISS), are unable to draw reliable subnational and subannual incidence estimates.Compared with the International Classification of Diseases (ICD), the clinical ontology system currently used widely in health care, NEISS's coding structure lacks specificity and consistency. In parallel, the quality of ICD codes depends on accurate and complete documentation by health care providers and skillful translation into ICD codes in electronic health care data. Additionally, there is no national mandate to collect external cause of injury data.Electronic health care data, such as health records and claims, with updated codes and uniform adherence to recommendations for coding external cause of injury, have the potential to be used for a more robust and timely surveillance of injury to accurately and reliably reflect the injury burden in the United States.


Assuntos
Registros Eletrônicos de Saúde/organização & administração , Vigilância em Saúde Pública/métodos , Ferimentos e Lesões/epidemiologia , Causalidade , Codificação Clínica , Confiabilidade dos Dados , Registros Eletrônicos de Saúde/normas , Humanos , Classificação Internacional de Doenças , Fatores de Tempo , Estados Unidos , Ferimentos e Lesões/mortalidade , Ferimentos e Lesões/prevenção & controle
11.
Ann Vasc Surg ; 56: 36-45, 2019 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-30500659

RESUMO

BACKGROUND: Firearm injuries can be morbid and potentially have high resource utilization. Historically, trauma and vascular surgery patients are at higher risk for readmissions. Our goal was to assess the risk for readmission among patients undergoing vascular repair after a firearm injury. METHODS: The National Readmission Database was queried from 2011 to 2014. All firearm injuries with or without vascular repair were analyzed. Multivariable analysis was conducted to assess the effect of concurrent vascular repair on readmissions at 30, 90, and 180 days. RESULTS: There were 42,184 firearm injury admissions identified, where 93.3% did not undergo vascular repair and 6.7% required vascular repair. The overall in-hospital death rate was 8.2%. Average age was 29.9 ± 0.2 years, and 89.2% were male. Intent was most frequently assault (61.2%) followed by unintentional injury (26.5%), suicide (5.2%), and legal intervention (3.1%). Patients with vascular repair compared to those without vascular repair were more frequently admitted at teaching hospitals (85.2% vs. 81.8%, P = 0.042), had higher Agency for Healthcare Research and Quality (AHRQ) extreme severity of illness, AHRQ risk of mortality, New Injury Severity Score (NISS), and had more diagnoses and procedures (P < 0.0001). Patients with vascular repair compared to those without vascular repair also more frequently sustained abdominal/pelvis injury (40.4% vs. 23.4%, P < 0.0001) and were more likely to have anemia (5.9% vs. 3.6%, P = 0.009). Patients undergoing vascular repair had a higher rate for 30-day (8.9% vs. 5.5%, P = 0.0001), 90-day (18.1% vs 9.5%, P < 0.0001), and 180-day (22.3% vs. 13%, P < 0.0001) readmission. Kaplan-Meier analysis of unadjusted data showed a higher readmission rate over time with vascular repair. Multivariable analysis demonstrated that vascular repair was not associated with higher 30-day readmission (odds ratio [OR] 1.26, 95% confidence interval [CI] 0.92-1.72, P = 0.14) but was for 90-day (OR 1.38, 95% CI 1.14-1.68, P = 0.001) and 180-day readmission (OR 1.24, 95% CI 1.06-1.45, P = 0.009). Additional factors associated with 30-day readmission were higher NISS, discharge to a care facility, and Elixhauser score. Other factors associated with 90-day readmission were unintentional intent of injury, NISS, discharge to a care facility, and Elixhauser score. Factors also associated with 180-day readmission were insurance type, unintentional intent of injury, NISS, care facility discharge, and Elixhauser score. CONCLUSIONS: Firearm injury resulting in vascular injury was associated with increased readmissions at 90 and 180 days. This study establishes baseline rates for readmission after vascular repair for firearm traumas and allows opportunity for improvement through targeted interventions for these patients. Vascular surgeons can have a more active role in managing this high-profile public health issue.


Assuntos
Armas de Fogo , Readmissão do Paciente , Procedimentos Cirúrgicos Vasculares/efeitos adversos , Lesões do Sistema Vascular/cirurgia , Ferimentos por Arma de Fogo/cirurgia , Adulto , Bases de Dados Factuais , Feminino , Humanos , Masculino , Estudos Retrospectivos , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , Estados Unidos/epidemiologia , Procedimentos Cirúrgicos Vasculares/mortalidade , Lesões do Sistema Vascular/diagnóstico , Lesões do Sistema Vascular/mortalidade , Ferimentos por Arma de Fogo/diagnóstico , Ferimentos por Arma de Fogo/mortalidade
12.
Am J Epidemiol ; 187(7): 1411-1419, 2018 07 01.
Artigo em Inglês | MEDLINE | ID: mdl-29590270

RESUMO

Dietary protein may help prevent age-related declines in strength and functional capacity. This study examines the independent relationship between dietary protein and longitudinal changes in physical functioning among adults participating in the Framingham Offspring Study from examination 5 (1991-1995) to examination 8 (2005-2008). Protein intakes were derived from 3-day diet records during examinations 3 and 5; functional status was determined over 12 years using 7 items selected from standardized questionnaires. Multivariable models adjusted for age, sex, education, physical activity, smoking, height, and energy intake. Functional tasks that benefitted most from a higher-protein diet (≥1.2 g/kg/day vs. <0.8 g/kg/day) were doing heavy work at home, walking 1/2 mile (0.8 km), going up and down stairs, stooping/kneeling/crouching, and lifting heavy items. Those with higher protein intakes were 41% less likely (95% CI: 0.43, 0.82) to become dependent in 1 or more of the functional tasks over follow-up. Higher physical activity and lower body mass index were both independently associated with less functional decline. The greatest risk reductions were found among those with higher protein intakes combined with either higher physical activity, more skeletal muscle mass, or lower body mass index. This study demonstrates that dietary protein intakes above the current US Recommended Daily Allowance may slow functional decline in older adults.


Assuntos
Envelhecimento/fisiologia , Proteínas Alimentares/análise , Ingestão de Energia/fisiologia , Exercício Físico/fisiologia , Envelhecimento Saudável/fisiologia , Atividades Cotidianas , Idoso , Índice de Massa Corporal , Inquéritos sobre Dietas , Feminino , Avaliação Geriátrica , Humanos , Estudos Longitudinais , Masculino , Pessoa de Meia-Idade , Força Muscular/fisiologia , Músculo Esquelético/fisiologia , Estado Nutricional
13.
J Vasc Surg ; 68(2): 372-382.e3, 2018 08.
Artigo em Inglês | MEDLINE | ID: mdl-29506946

RESUMO

OBJECTIVE: The care of patients undergoing thoracic endovascular aortic repair (TEVAR) can be resource intensive, which can be driven by readmissions. Our objective was to characterize index readmissions at 30, 90, and 180 days after TEVAR. METHODS: A retrospective analysis of the Nationwide Readmissions Database was performed for patients who underwent TEVAR in 2013. Multivariable analysis identified independent predictors for index readmission at 30, 90, and 180 days. RESULTS: There were 4045 TEVARs performed for descending thoracic aortic dissection (37.7%), nonruptured aneurysm (56%), and ruptured aneurysm (6.3%). There were 419 (11.1%) index readmissions at 30 days, 895 (23.6%) at 90 days, and 1131 (29.8%) at 180 days. The most frequent reason for index readmission was heart related at 30 days (15.5%) and aorta related at 90 days (18%) and 180 days (19.6%). Reinterventions were performed at 6.4%, 9.5%, and 9.7% of 30-, 90-, and 180-day readmissions, respectively. The majority of these included additional endovascular stent graft placement (51.9% of reinterventions at 30 days, 67.7% at 90 days, and 65.9% at 180 days). In multivariable analysis, 30-day index readmission was associated with initial ruptured presentation (odds ratio [OR], 1.48; 95% confidence interval [CI], 1.1-3.5; P = .023) and diagnosis-related group (DRG) severity grades of moderate (OR, 1.42; 95% CI, 0.74-2.73), major (OR, 2.47; 95% CI, 1.28-4.74), and extreme (OR, 1.60; 95% CI, 0.76-3.36; P = .009). Index readmission at 90 days was independently associated with initial ruptured presentation (OR, 1.88; 95% CI, 1.18-3.01; P = .008), urgent/emergent TEVAR (OR, 1.41; 95% CI, 1.08-1.85; P = .014), and DRG severity grades of moderate (OR, 1.53; 95% CI, 0.95-2.47), major (OR, 2.27; 95% CI, 1.39-3.7), and extreme (OR, 2.45; 95% CI, 1.43-4.18; P = .002). Finally, at 180 days, initial ruptured presentation (OR, 1.66; 95% CI, 1.05-2.62; P = .029), urgent/emergent TEVAR (OR, 1.37; 95% CI, 1.08-1.79; P = .013), and DRG severity grades of moderate (OR, 1.55; 95% CI, 1.01-2.38), major (OR, 2.15; 95% CI, 1.38-3.33), and extreme (OR, 2.39; 95% CI, 1.47-3.89; P = .002) were, again, independently associated with index readmission. CONCLUSIONS: A large portion of patients treated with TEVAR were readmitted most commonly for heart-related reasons at 30 days and aorta-related reasons at 90 and 180 days. TEVAR performed to treat initial aortic rupture and greater DRG severity grade were independently associated with an index readmission at 30, 90, and 180 days. Urgent/emergent TEVAR was independently associated with an index readmission at 90 and 180 days. These factors are important to consider in using readmissions as a quality measure.


Assuntos
Aneurisma da Aorta Torácica/cirurgia , Dissecção Aórtica/cirurgia , Ruptura Aórtica/cirurgia , Implante de Prótese Vascular/efeitos adversos , Procedimentos Endovasculares/efeitos adversos , Readmissão do Paciente , Complicações Pós-Operatórias/etiologia , Idoso , Dissecção Aórtica/diagnóstico por imagem , Dissecção Aórtica/mortalidade , Aneurisma da Aorta Torácica/diagnóstico por imagem , Aneurisma da Aorta Torácica/mortalidade , Ruptura Aórtica/diagnóstico por imagem , Ruptura Aórtica/mortalidade , Implante de Prótese Vascular/mortalidade , Distribuição de Qui-Quadrado , Comorbidade , Bases de Dados Factuais , Procedimentos Endovasculares/mortalidade , Feminino , Cardiopatias/epidemiologia , Humanos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Razão de Chances , Complicações Pós-Operatórias/diagnóstico por imagem , Complicações Pós-Operatórias/mortalidade , Complicações Pós-Operatórias/cirurgia , Prevalência , Reoperação , Estudos Retrospectivos , Fatores de Risco , Índice de Gravidade de Doença , Fatores de Tempo , Resultado do Tratamento , Estados Unidos/epidemiologia
14.
Ann Intern Med ; 167(8): 536-543, 2017 Oct 17.
Artigo em Inglês | MEDLINE | ID: mdl-28975202

RESUMO

BACKGROUND: To prevent intimate partner homicide (IPH), some states have adopted laws restricting firearm possession by intimate partner violence (IPV) offenders. "Possession" laws prohibit the possession of firearms by these offenders. "Relinquishment" laws prohibit firearm possession and also explicitly require offenders to surrender their firearms. Few studies have assessed the effect of these policies. OBJECTIVE: To study the association between state IPV-related firearm laws and IPH rates over a 25-year period (1991 to 2015). DESIGN: Panel study. SETTING: United States, 1991 to 2015. PARTICIPANTS: Homicides committed by intimate partners, as identified in the Federal Bureau of Investigation's Uniform Crime Reports, Supplementary Homicide Reports. MEASUREMENTS: IPV-related firearm laws (predictor) and annual, state-specific, total, and firearm-related IPH rates (outcome). RESULTS: State laws that prohibit persons subject to IPV-related restraining orders from possessing firearms and also require them to relinquish firearms in their possession were associated with 9.7% lower total IPH rates (95% CI, 3.4% to 15.5% reduction) and 14.0% lower firearm-related IPH rates (CI, 5.1% to 22.0% reduction) than in states without these laws. Laws that did not explicitly require relinquishment of firearms were associated with a non-statistically significant 6.6% reduction in IPH rates. LIMITATIONS: The model did not control for variation in implementation of the laws. Causal interpretation is limited by the observational and ecological nature of the analysis. CONCLUSION: Our findings suggest that state laws restricting firearm possession by persons deemed to be at risk for perpetrating intimate partner abuse may save lives. Laws requiring at-risk persons to surrender firearms already in their possession were associated with lower IPH rates. PRIMARY FUNDING SOURCE: Robert Wood Johnson Foundation.


Assuntos
Armas de Fogo/legislação & jurisprudência , Homicídio/estatística & dados numéricos , Violência por Parceiro Íntimo/estatística & dados numéricos , Ferimentos por Arma de Fogo/mortalidade , Humanos , Estados Unidos/epidemiologia , Ferimentos por Arma de Fogo/prevenção & controle
15.
Am J Epidemiol ; 185(7): 546-553, 2017 04 01.
Artigo em Inglês | MEDLINE | ID: mdl-28338922

RESUMO

Investigating firearm injury trends over the past decade, we examined temporal trends overall and according to race/ethnicity and intent in fatal and nonfatal firearm injuries (FFIs and NFIs) in United States during 2001-2013. Counts of FFIs and estimated counts of NFIs were obtained from the Centers for Disease Control and Prevention's Web-based Injury Statistics Query and Reporting System. Poisson regression was used to analyze overall and subgroup temporal trends and to estimate annual change per 100,000 persons (change). Total firearm injuries (n = 1,328,109) increased annually by 0.36 (Ptrend < 0.0001). FFIs remained constant (change = 0.02; Ptrend = 0.22) while NFIs increased (change = 0.35; Ptrend < 0.0001). Homicide FFIs declined (change = -0.05; Ptrend < 0.0001) while homicide NFIs increased (change = 0.43; Ptrend < 0.0001). Suicide FFIs increased (change = 0.07; Ptrend < 0.0001) while unintentional FFIs and NFIs declined (changes = -0.01 and -0.09, respectively; Ptrend < 0.0001 and 0.005). Among whites, FFIs (change = 0.15; Ptrend < 0.0001) and NFIs (change = 0.13; Ptrend < 0.0001) increased; among blacks, FFIs declined (change = -0.20; Ptrend < 0.0001). Among Hispanics, FFIs declined (change = -0.28; Ptrend < 0.0001) while NFIs increased (change = 0.55; Ptrend = 0.014). The endemic firearm-related injury rates during the first decade of the 21st century mask a shift from firearm deaths towards a rapid rise in nonfatal injuries.


Assuntos
Ferimentos por Arma de Fogo/epidemiologia , Acidentes/mortalidade , Acidentes/estatística & dados numéricos , Adolescente , Adulto , Criança , Pré-Escolar , Feminino , Armas de Fogo/estatística & dados numéricos , Homicídio/estatística & dados numéricos , Humanos , Lactente , Masculino , Pessoa de Meia-Idade , Distribuição de Poisson , Grupos Raciais/estatística & dados numéricos , Suicídio/estatística & dados numéricos , Estados Unidos/epidemiologia , Ferimentos por Arma de Fogo/mortalidade , Adulto Jovem
16.
Lancet ; 387(10030): 1847-55, 2016 Apr 30.
Artigo em Inglês | MEDLINE | ID: mdl-26972843

RESUMO

BACKGROUND: In an effort to reduce firearm mortality rates in the USA, US states have enacted a range of firearm laws to either strengthen or deregulate the existing main federal gun control law, the Brady Law. We set out to determine the independent association of different firearm laws with overall firearm mortality, homicide firearm mortality, and suicide firearm mortality across all US states. We also projected the potential reduction of firearm mortality if the three most strongly associated firearm laws were enacted at the federal level. METHODS: We constructed a cross-sectional, state-level dataset from Nov 1, 2014, to May 15, 2015, using counts of firearm-related deaths in each US state for the years 2008-10 (stratified by intent [homicide and suicide]) from the US Centers for Disease Control and Prevention's Web-based Injury Statistics Query and Reporting System, data about 25 firearm state laws implemented in 2009, and state-specific characteristics such as firearm ownership for 2013, firearm export rates, and non-firearm homicide rates for 2009, and unemployment rates for 2010. Our primary outcome measure was overall firearm-related mortality per 100,000 people in the USA in 2010. We used Poisson regression with robust variances to derive incidence rate ratios (IRRs) and 95% CIs. FINDINGS: 31,672 firearm-related deaths occurred in 2010 in the USA (10·1 per 100,000 people; mean state-specific count 631·5 [SD 629·1]). Of 25 firearm laws, nine were associated with reduced firearm mortality, nine were associated with increased firearm mortality, and seven had an inconclusive association. After adjustment for relevant covariates, the three state laws most strongly associated with reduced overall firearm mortality were universal background checks for firearm purchase (multivariable IRR 0·39 [95% CI 0·23-0·67]; p=0·001), ammunition background checks (0·18 [0·09-0·36]; p<0·0001), and identification requirement for firearms (0·16 [0·09-0·29]; p<0·0001). Projected federal-level implementation of universal background checks for firearm purchase could reduce national firearm mortality from 10·35 to 4·46 deaths per 100,000 people, background checks for ammunition purchase could reduce it to 1·99 per 100,000, and firearm identification to 1·81 per 100,000. INTERPRETATION: Very few of the existing state-specific firearm laws are associated with reduced firearm mortality, and this evidence underscores the importance of focusing on relevant and effective firearms legislation. Implementation of universal background checks for the purchase of firearms or ammunition, and firearm identification nationally could substantially reduce firearm mortality in the USA. FUNDING: None.


Assuntos
Armas de Fogo/legislação & jurisprudência , Homicídio/estatística & dados numéricos , Suicídio/estatística & dados numéricos , Ferimentos por Arma de Fogo/mortalidade , Estudos Transversais , Humanos , Estados Unidos/epidemiologia
17.
Trop Med Int Health ; 22(7): 839-845, 2017 07.
Artigo em Inglês | MEDLINE | ID: mdl-28510998

RESUMO

OBJECTIVE: To assess the incidence and associated factors of Type 2 Diabetes Mellitus (T2DM) among people living with HIV (PLHIV) in Zimbabwe. METHODS: We analysed data of all HIV-infected patients older than 16 years who attended Newlands Clinic between March 1, 2004 and April 29, 2015. The clinic considers patients whose random blood sugar is higher than 11.1 mmol/l and which is confirmed by a fasting blood sugar higher than 7.0 mmol/l to have T2DM. T2DM is also diagnosed in symptomatic patients who have a RBS >11.0 mmol/l. Risk factors for developing T2DM were identified using Cox proportional hazard models adjusted for confounding. Missing baseline BMI data were multiply imputed. Results are presented as adjusted hazard ratios (aHR) with 95% confidence intervals (95% CI). RESULTS: Data for 4,110 participants were included: 67.2% were women; median age was 37 (IQR: 31-43) years. Median baseline CD4 count was 197 (IQR: 95-337) cells/mm3 . The proportion of participants with hypertension at baseline was 15.5% (n=638). Over a median follow-up time of 4.7 (IQR: 2.1-7.2) years, 57 patients developed T2DM; the overall incidence rate was 2.8 (95% CI: 2.1-3.6) per 1000 person-years of follow-up. Exposure to PIs was associated with T2DM (HR: 1.80, 95% CI: 1.04-3.09). In the multivariable analysis, obesity (BMI>30 kg/m2 ) (aHR=2.26, 95% CI: 1.17-4.36), age >40 years (aHR=2.16, 95% CI: 1.22-3.83) and male gender, (aHR=2.13, 95% CI: 1.22-3.72) were independently associated with the risk of T2DM. HIV-related factors (baseline CD4 cell count and baseline WHO clinical stage) were not independent risk factors for developing T2DM. CONCLUSION: Although the incidence of T2DM in this HIV cohort was lower than that has been observed in others, our results show that risk factors for developing T2DM among HIV-infected people are similar to those of the general population. HIV-infected patients in sub-Saharan Africa need a comprehensive approach to care that includes better health services for prevention, early detection and treatment of chronic diseases especially among the elderly and obese.


Assuntos
Diabetes Mellitus Tipo 2/epidemiologia , Infecções por HIV/epidemiologia , Adulto , Estudos de Coortes , Comorbidade , Feminino , Humanos , Incidência , Masculino , Estudos Retrospectivos , Zimbábue/epidemiologia
18.
Am J Public Health ; 107(7): 1122-1129, 2017 07.
Artigo em Inglês | MEDLINE | ID: mdl-28520491

RESUMO

OBJECTIVES: To describe a new database containing detailed annual information on firearm-related laws in place in each of the 50 US states from 1991 to 2016 and to summarize key trends in firearm-related laws during this time period. METHODS: Using Thomson Reuters Westlaw data to access historical state statutes and session laws, we developed a database indicating the presence or absence of each of 133 provisions of firearm laws in each state over the 26-year period. These provisions covered 14 aspects of state policies, including regulation of the process by which firearm transfers take place, ammunition, firearm possession, firearm storage, firearm trafficking, and liability of firearm manufacturers. RESULTS: An examination of trends in state firearm laws via this database revealed that although the number of laws nearly doubled during the study period, there was substantial heterogeneity across states, leading to a widening disparity in the number of firearm laws. CONCLUSIONS: This database can help advance firearm policy research by providing 26 years of comprehensive policy data that will allow longitudinal panel study designs that minimize the limitations present in many previous studies.


Assuntos
Armas de Fogo/legislação & jurisprudência , Propriedade/estatística & dados numéricos , Propriedade/tendências , Bases de Dados Factuais/estatística & dados numéricos , Regulamentação Governamental , Humanos , Políticas , Estados Unidos
19.
Am J Public Health ; 107(12): 1923-1929, 2017 12.
Artigo em Inglês | MEDLINE | ID: mdl-29048964

RESUMO

OBJECTIVES: To examine the relation of "shall-issue" laws, in which permits must be issued if requisite criteria are met; "may-issue" laws, which give law enforcement officials wide discretion over whether to issue concealed firearm carry permits or not; and homicide rates. METHODS: We compared homicide rates in shall-issue and may-issue states and total, firearm, nonfirearm, handgun, and long-gun homicide rates in all 50 states during the 25-year period of 1991 to 2015. We included year and state fixed effects and numerous state-level factors in the analysis. RESULTS: Shall-issue laws were significantly associated with 6.5% higher total homicide rates, 8.6% higher firearm homicide rates, and 10.6% higher handgun homicide rates, but were not significantly associated with long-gun or nonfirearm homicide. CONCLUSIONS: Shall-issue laws are associated with significantly higher rates of total, firearm-related, and handgun-related homicide.


Assuntos
Armas de Fogo/legislação & jurisprudência , Homicídio/estatística & dados numéricos , Ferimentos por Arma de Fogo/mortalidade , Distribuição por Idade , Humanos , Estados Unidos/epidemiologia
20.
Inj Prev ; 23(5): 321-327, 2017 10.
Artigo em Inglês | MEDLINE | ID: mdl-27923800

RESUMO

BACKGROUND: Data on the factors associated with school shootings in the USA are limited. The public conversation has often suggested several factors that may be linked to these events, however with little empirical support. Aiming to fill this gap, we describe the characteristics of school shooting incidents in the USA between 2013 and 2015 and explore whether four factors that represent domains of firearm policy, educational policy and epidemiological risk factors for intentional firearm injuries-background check (BC) policies, per capita mental health expenditures (MHE), K-12 education expenditure (KEE) and urbanicity-were associated with school shootings during this period. METHODS: We searched LexisNexis, a newspaper and broadcast media databases for school shooting incidents from 1 January 2013 to 31 December 2015. Presence of BC laws was extracted from legal information in LexisNexis. State-level covariates of per capita MHE (2013), KEE (2013) and urbanicity (2010) rates were obtained from publicly available data sources. We used negative binomial regression models accounting for clustering by state to explore unadjusted associations between the BC laws, state-level covariates and school shootings to report IRR and 95% CI. RESULTS: We documented 154 school shootings (35, 55 and 64 each year). In unadjusted models, BC for firearm purchase (IRR=0.55, 95% CI 0.39 to 0.76), ammunition purchase (IRR=0.11, 95% CI 0.05 to 0.27), log per capita MHE (IRR=0.58, 95% CI 0.37 to 0.90), log per-capita KEE (IRR=0.09, 9% CI 0.02 to 0.29) and urbanicity (IRR=0.97, 95% CI 0.96 to 0.99) were associated with school shooting. CONCLUSIONS: School shootings are less likely in states with BC laws, higher MHE and KEE, and with greater per cent urban population.


Assuntos
Armas de Fogo , Homicídio/estatística & dados numéricos , Incidentes com Feridos em Massa/estatística & dados numéricos , Propriedade/legislação & jurisprudência , Política Pública , Instituições Acadêmicas , Suicídio/estatística & dados numéricos , Ferimentos por Arma de Fogo/epidemiologia , Adolescente , Adulto , Fatores Etários , Criança , Feminino , Armas de Fogo/legislação & jurisprudência , Humanos , Incidência , Masculino , População Rural , Instituições Acadêmicas/legislação & jurisprudência , Fatores Sexuais , Estados Unidos/epidemiologia , População Urbana , Adulto Jovem
SELEÇÃO DE REFERÊNCIAS
DETALHE DA PESQUISA